A 55-year-old man with lung cancer recently had the lower lobe of his left lung removed. Post-operatively, he was awake, alert, and oriented to time, place, and person. He was, however, malnourished from his cancer and experiencing significant pain at the surgical site. He had a chest tube and a urinary catheter in place, but was breathing on his own. The patient's pain was well controlled with fentanyl and bupivacaine administered through an epidural catheter. He was receiving total parenteral nutrition (TPN) and lipids through a central venous catheter inserted in his left jugular vein.
Nurse A, assigned to the patient, left the unit for her regularly scheduled break. Before leaving, she prepared a new bottle of lipids and left it at the bedside, as the current bottle would run out while she was off the floor. When the old bottle of lipids was empty, Nurse B, covering the patient during the primary nurse's break, inadvertently attached the new lipid bottle to the Y-site of the epidural tubing rather than the central venous line.
Upon her return, Nurse A noted that the new bottle of lipids was infusing but did not check the lines. Lipids infused into the epidural catheter for several hours. The problem was not discovered until the nurses on the next shift made rounds and checked the patient's tubing. Fortunately, the patient experienced no adverse effects from the infusion of lipids into his epidural space.
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